Health care in small prisons: incorporating high-quality standards Jean-Pierre Rieder, Alejandra Casillas, Ge´rard Mary, Anne-Dominique Secretan, Jean-Michel Gaspoz and Hans Wolff
Jean-Pierre Rieder, Alejandra Casillas, Ge´rard Mary, Anne-Dominique Secretan, Jean-Michel Gaspoz and Hans Wolff are based in the Unit of Penitentiary Medicine, Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland.
Abstract Purpose – In the past, health management in Geneva’s six post-trial prisons had been variable and inconsistent. In 2008, the unit of penitentiary medicine of the Geneva University Hospitals was mandated to re-organize and provide health care at all six prison facilities. The specific aim of this paper is to outline the example as a practical solution to some of the common challenges in unifying the structure and process of health services across multiple small facilities, while meeting European prison health and local quality standards. Design/methodology/approach – Geneva’s post-trial prisons are small and close to one another in geographical proximity – ideal conditions for the construction of a health mobile team (HMT). This multidisciplinary mobile team operated like a community ambulatory care model; it was progressively launched in all prison facilities in Geneva. The authors incorporated an implementation strategy where health providers partnered with prison and community stakeholders in the health delivery model’s development and adaption process. Findings – The model’s strategic initiatives are described along the following areas, in light of other international prison health activity and prior care models: access to a health care professional, equivalence of care, patient consent, confidentiality, humanitarian interventions, and professional competence and independence. Originality/value – From the perspective of the HMT members, the authors provide the ‘‘lessons learned’’ through this experience, especially to providers who are working on prison health services reform and coordination improvement. The paper particularly stresses the importance of partnering with community health stakeholders and prison staff, a key component to the approach. Keywords Prisons, Mobile health unit, Health care team, Community health network, Interdisciplinary health team, Health care quality, Access, Evaluation, Switzerland, Health services Paper type Case study
List of acronyms CPT GP HMT HUG OST WHO
¼ European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment ¼ general practitioner ¼ health mobile team ¼ Geneva University Hospitals ¼ opioid substitution therapy ¼ World Health Organization
Background: benchmarks and organization of prison health in Geneva Geneva, one of 26 Swiss cantons, measures 245.6 km2 for 467,748 residents (Republic and Canton of Geneva, 2011). Geneva possesses the largest pre-trial prison in Switzerland (Champ-Dollon, 370 places), as well as six post-trial prisons with space for a total of 165 people: one for women (nine places) and five for men (18-68 places). The post-trial prisons employ two detention regimens: ordinary (full-time detention) or external work/semi-detention (detainees go to work during the day but stay at the facility at night and on weekends) (Table I).
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VOL. 9 NO. 1 2013, pp. 20-30, Q Emerald Group Publishing Limited, ISSN 1744-9200
DOI 10.1108/17449201311310779
Table I Post-trial detention facilities in Geneva and their main characteristics Facility
Inmate capacity
La Brenaz
68 (men)
Favra
25 (men)
Montfleury
18 (men)
Raint Parc
9 (women)
La Vallon
24 (men)
Villars
21 (men)
Characteristics Standard detention Mostly undocumented immigrants Standard detention Mostly undocumented immigrants External work Socio-educational environment Mostly Swiss or documented immigrants Standard detention, semi-detention, and external work Swiss, documented and undocumented migrants External work Socio-educational environment Mostly Swiss or documented immigrants Standard detention, semi-detention, and external work Mostly Swiss or documented immigrants
Notes: Standard detention – full-time detention; semi-detention – part-time detention for people with a job; external work – part-time detention for people with a job after a period of ordinary detention and prior to release
The penitentiary medicine unit is now managed by the Geneva University Hospitals (HUG) system. Independent of prison administration and organized according to cantonal law (Republic and Canton of Geneva, 2000), the unit provides care in compliance with recommended standards (Swiss Academy of Medical Sciences, 2002; Council of Europe, 2006; Møller et al., 2007) (Table II). However, up until 2008, health care in the post-trial facilities had been organized in a variable and inconsistent manner: some prisons employed a nurse and/or a physician, while others had only the community emergency system as a resource. After an internal review between the local government, HUG and the Geneva penitentiary office, the involved stakeholders deemed that the prison health system was currently insufficient and needed re-organization.
Prison health mobile team: aims and conception In 2008, HUG was tasked by the cantonal government to organize and coordinate health care among all of the cantonal facilities to ensure independent, un-biased, provider-driven, quality care, in collaboration with community and prison staff partner feedback. The purpose of coordination was to standardize health care activities in the various prison facilities, in order to achieve more consistent adherence to prison health guidelines and unit congruence regarding health-services offered. Table II Fundamental principles of prison medicine Access to a doctor
Any detained person must have access to a doctor at any moment, whatever his/her judiciary or administrative status may be Equivalence of care For a given health issue, detained people must receive care that is equivalent to the health care given to un-imprisoned people of the same region Patient consent Prisoners with decision-making capacity have the right to informed consent for all treatments and procedures, and their decisions must be respected, as done for patients residing in the community Confidentiality Health providers must safeguard the confidentiality of medical information about detained patients Sanitary prevention In addition to individual care, prison health services have a social and preventive medicine mission, particularly with regard to hygiene, transmittable diseases, suicide, violence, and the preservation of social and family ties Humanitarian Health staff in prison should give special attention to groups who are particularly vulnerable: (pregnant) intervention women, immigrants, youth, the elderly, the mentally ill, and the critically/terminally ill Professional competence Health staff in prison should have specific skills and knowledge regarding health topics of high relevance for imprisoned people Professional Health staff in prison should be in a position to make decisions solely on the basis of medical judgment. This independence independence is better ensured when health providers are part of the community health system, separate from the control of judicial administration Source: CPT (2006)
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In re-designing care, one obvious option for improvement was to create health services for each site – with a smaller and autonomous health team at each facility. Another proposal was to have two-three teams for the group of facilities. The perceived advantage of these options was the continued visibility of health providers. But from anecdotal experiences, we quickly agreed that such plans would not be realistic or sustainable given their high financial costs, potential lack of coordination, inefficiency and ineffective use of resources. Geneva’s post-trial facilities are small; they have various missions and objectives, and they each shelter specific populations (Table I). For a cluster of small facilities, we envisioned that a part-time, mobile, and easily accessible health team could respond to prisoner health problems without requiring the continued and costly presence of a doctor or a nurse. Because of their small sizes and the short travelling distances in Geneva, the model of a singular primary mobile team was quickly accepted as the best option: it required less staff and equipment, but would have a central structure to facilitate flow of information between team members and coordination among the facilities. Our health mobile team (HMT) is multidisciplinary. It is comprised of nurses, a general practitioner (GP), a psychiatrist, a psychologist, and a secretary. Our team offers access to dental health providers, working in close collaboration with the dentists of Champ-Dollon (the HMT’s ‘‘home base’’). The team collaborates with the prisons’social workers, all-the-while maintaining professional confidentiality. The care management concept is based on the European Prison Rules (Council of Europe, 2006) and the European Committee for the Prevention of Torture (CPT) rules (CPT, 2006). We will discuss the HMT’s main initiatives along the following action areas (in italics below): access to a health care professional, equivalence of care, patient consent, confidentiality, humanitarian interventions, professional competence and independence. We also make referential comparisons to what other international prison models have done in the past in the context of these action areas. Access to a health care professional Access to a health care professional is organized in different ways among prisons worldwide. The access process varies from nurses or a doctor available 24 h a day within the prison, e.g. Champ-Dollon in Geneva/Switzerland (Wolff et al., 2011), Casa di Reclusione in Padova, Italy (Pirruccio, 2011), to no health professional available (complete dependence on the local community’s emergency room services). Similar mechanisms existed in Geneva before the launch of the HMT. Some facilities were equipped with a daily nurse with the help of a visiting doctor twice a week. Other units simply had the one nurse on-call, without any sort of physician backup ensured. Neither example was efficient nor in accordance with the European rules in terms of ensuring access. Our current model is an ambulatory team with nurse gate-keeping. The team works on weekdays (Monday-Friday, from 7 am to 6 pm) and has its primary base in the largest facility (La Brenaz, 68 places). The team visits the other facilities on a regular basis (pre-appointed days) with a frequency proportionate to each one’s size and according to acute need. An interpreting service is used when needed. All new inmates undergo a health screening with a nurse within 24-48 h of admission. The purpose of this screen is to identify any problems needing more immediate attention: addictions, infectious disease risk, suicidal ideation and need for continuing/initiating treatment. The nurse refers the patient to the most appropriate health professional on the team, as he/she sees fit. If necessary, the GP then refers the person to consult with a specialist, as done with any community-dwelling patient at the HUG. Two prisoner-only wards at the HUG (medical and psychiatric) care for prisoners in the inpatient setting. In the case of an urgent and acute medical problem, the prison officers call an HMT nurse for evaluation. Outside of working hours, the community emergency network is the appropriate health resource. If the problem appears to be an emergency, prison officers have the discretion to call an ambulance at any moment. In the time since the HMT has been implemented, there has been much discussion between prison staff and HMT providers
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about when to escalate care. In response to these discussions, our nurses, GP, and local pharmacists have developed a guideline outlining appropriate staff responses for ’’everyday problems’’ (e.g. pain, anxiety, small wounds), indicating an appropriate course of action: from basic symptomatic treatment on issues that can wait on provider evaluation, to more escalated measures like immediate evaluation by the HMT, or calling emergency medical services. However, during working hours, the prison officers are encouraged to call the HMT for any prisoner medical issue if the next course of action is not obvious. Equivalence of care Matching health care to what is offered in the surrounding community is a challenge. Our goal is ambitious given that the team seeks to provide equivalent care with respect to all aspects of health promotion, prevention, diagnostic processes and therapies for every detainee regardless of his/her social or administrative status. Worldwide, the failure to achieve equivalence of care in prison is a major issue (CPT, 2006). This is simply because the volume of challenging medical issues among this population is high (Fazel and Baillargeon, 2011). For example, drug addictions are far more prevalent among detainees compared to the general population (Table III). Therefore, successful therapeutic plans like opioid substitution therapy (OST) and needle-syringe exchange programs (NSP) are alternatives that should be offered to candidate patients who meet medical treatment criteria. However, OST is available in 77 countries only and among this small group, only 41 of these countries offer OST in prison (International Harm Reduction Association, 2012). In addition, the situation is far worse than the statistics first indicate – the presence of prison OST in one country does not translate to OST availability in every prison of that country. The situation for NSP is similar (International Harm Reduction Association, 2012). Following the community’s local law and in the name of equivalence of care, our team provides comparable health services in prison to those available in the community, including OST and NSP. The team also provides infectious disease screenings, vaccinations and treatment, thus focusing our efforts on aspects of primary, secondary and tertiary prevention. Patient consent and patient decision-making Informed consent for patients is required for every medical intervention that the team delivers. The HMT never engages in medical treatment against the patient’s will, except in cases of psychiatric commitment and where patients are deemed incompetent, per the same legal criteria employed in the community (Swiss Confederation, 1981). Unfortunately however, violations of patient consent and decision-making are not uncommon in prison settings. Common examples are international cases of prisoner hunger strikers followed by forcedfeedings of these individuals; a violation of the European Court of Human Rights (2005) (Lacopino and Xenakis, 2011). In our setting, in contrast to several countries, competent hunger strikers are never force-fed and their advance directives about feeding procedures (and all treatments) are honored should they lose consciousness. This is all in accordance with the European rules and the Malta Declaration (World Medical Association, 1991).
Table III Types of addiction among the Swiss general population (2007) (Swiss Federal Statistical Office, 2008) and the detainees of Champ-Dollon remand prison, Switzerland (2007-2008) (Wolff et al., 2011)
Substance Alcohol Tobacco Benzodiazepines Heroin Cocaine Cannabis
Prevalence (general Swiss population) (%)
Prevalence (detainees of Champ-Dollon) (%)
4.7 30.5 1.3-2.1 ,1 ,1 9-31 (depending on age)
20 61 22 12 20 28
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Confidentiality Because the HMT promotes patient autonomy and right to confidentiality, any inmate seeking a health visit can place a sealed written request in our letterbox (located at each facility). Although this appears simple, it is very efficient. Requests are sometimes rudimentary but these are systematically evaluated by a nurse to determine the urgency level and to whom the inmate should be referred. Nurses are able to resolve numerous problems without involving the doctor. Urgent requests are immediately relayed through prison staff. However, consultations never take place in the presence of prison staff. Medical information is not given to anyone without authorization by the patient (even to his/her lawyer or a judge). Humanitarian interventions All detainees are part of a vulnerable population. However, within this population, certain subgroups like women, minors, immigrants, those with poor language proficiency (non-native speakers), the mentally ill, and elderly detainees are particularly vulnerable (Ferszt, 2011; Rieder et al., 2010; Fraser et al., 2007; Stojkovic, 2007; Golzari et al., 2006; Wolff et al., 2011). In our operations, these groups receive special attention in order to ensure that they are not subject to abuse or mistreatment given their vulnerable status, that they are well-informed about their rights and that they have access to an interpreter if needed. For example, in cases of patients reporting violence or any abuse to their providers, a medical incident report is written by the team in order to allow the incarcerated patient to make a formal complaint. If any authorities (police, prison officers) are involved, an independent ombudsman acting as a correctional and police investigator is systematically informed. Another example of these humanitarian efforts in prison is the specific services that are made available to our patients who would otherwise have no recourse to such specialized treatments, even in the community setting. The HMToffers services such as mental health and addiction therapies and also costly treatments for infectious diseases like hepatitis C. This is simultaneously an altruistic action, as treating these diseases improve the local communities. Tan et al. (2008) reported that treating hepatitis C in prison is not only cost effective, but also confers health benefits in terms of the individual and the public health status. Therefore, imprisonment can be considered an important opportunity for prison staff, health providers and public health administrators to impact the well-being of their community: treating the illnesses of the most difficult-to-reach populations who live at the margins of society, whose illnesses and outcomes also have a significant effect on the health of the community. Professional competence Providers with up-to-date knowledge and skills are crucial in ensuring high-quality standards. The Kyrgyz example illustrates the limitations met by under-trained or non-specifically educated teams. In this setting, medical providers were mostly early in their career course or training, without sufficient practical and/or professional prison medicine experience, per the World Health Organization (WHO) evaluation. Problems in this setting were inadequate disease monitoring, un-organized medical consultations and failure of medical follow-up, which (per the report) were partly due to the lack of experience and knowledge of prison health among medical providers (WHO, 2010). In contrast, all members of the HMT are employed by the HUG and must satisfy the same quality standards and continuing medical education as those seasoned expert colleagues working in other units of the university hospitals. They have all had extensive training and experience in prison health care (recruited from Champ-Dollon) and are effectively ‘‘specialists’’ in prison medicine. Professional independence The European prison rules and the European CPT recommend that prison health providers must be linked to the civil health authority (department of health, local health ministry) and function independently of the correctional setting from an employment standpoint. The HMT model functions in this manner. This ensures supervisorial distance from the prison and facilitates medical decisions with the patient’s best interests in mind (Geneva Declaration on Health Care in Prison, 2012). The professional independence of the HMT is safeguarded by
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the fact that all medical responsibility and liability fall under the auspices of the HUG. This prevents dual loyalty conflicts or other ethical problems that can occur in settings where health professionals are employed by the justice department/prison (Pont et al., 2012). However, ‘‘independence’’ does not translate into ‘‘avoidance.’’ Regular planned meetings with prison directors are indispensable in our model, where we jointly monitor and discuss any complicated cases that need special attention. These meetings have also been a way to convey positive feedback to our partners (giving commendation to prison activities, communication and staff actions which facilitate quality health delivery by the HMT). These consistent meetings have improved coordination and collaboration over time, as our respective roles have become more clearly defined to all involved: the prison administration being responsible for the prison’s security operations, while the HMT directs health services for patients and acts as the safeguard for fundamental health principles in prison (Table II).
Launch of the HMT: working together From the outset, one of our greatest challenges was to implement reform without provoking a surge of resistance from prison custodial staff. Several meetings with the prison partners before and after our launch identified multiple issues specific to each facility and the need for the mobile team to build collegial relationships with prison leaders and everyday staff. We provide specific examples of our collaborative approach drawing from the following two experiences: 1. compromising with prison leadership in relation to medication management; and 2. outreach to community organizations, vital to achieving patient continuity of care. Partnering and relationship building with prison staff and community colleagues, where all stakeholders had a valued and respected voice, was a key ingredient for the model’s implementation. This helped our partners view the new presence of the HMT providers as an advantage, rather than a threat. Working together – prison leadership and medication management Medication management in prison is a complicated challenge as it reveals the perhaps competing, and often not always aligned, goals of health professionals and custodial staff. In accordance with the health principles of equivalence of care, confidentiality, and autonomy, detainees should have the right to manage their own treatment. However, most of our prison management partners did not accept this framework. Initially, heads-of-facilities preferred total security and control of medication management – even in cases where a prisoner’s stay was short or his/her release was soon approaching. But after many meetings, compromises were possible given our stable presence in the prisons and continued conversations with prison leaders and partners. These conversations sensitized the prison management to the HMT’s ultimate mission: to prepare inmates for release into the community in the best condition possible (mentally and physically), so as to become contributing members of society. Ironically, settings in which the prison’s management refused to impose drug management duties on prison wardens, worked in our favor. This paradigm completely removed prison officers from the equation and more easily promoted autonomy, self-responsibility and the right to confidentiality. However, these types of leadership reactions also made it difficult for our team to administer therapies like OST, since these require direct observation: without prison leadership buy-in and assistance, our man-power resources would not have been capable of providing such oversight. Thus, medication management was tailored to each facility, but never betrayed the core principles of prison health. Currently in some facilities, the nurses administer individual treatments twice a week to each patient. In other prisons, the nurses prepare the weekly pillboxes, leaving the wardens to present the boxes to the patient several times a day (and the patient takes his/her medications at that moment). In all cases, the wardens are solely responsible for identifying the patients and never for the content of the pillboxes.
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Working together – community outreach and continuity of patient care In conjunction with local community health services, the HMT communicates with all previous, present and future partners pertinent to the patient’s case (e.g. prison or community health services, addiction medicine, psychiatry or other specialty services, migrant care centers, non-government and charity organizations). Because the HMT is a recent development, the team has been extremely proactive in making contacts and establishing regular, long-term communication with community organizations that are pertinent to the prisoner population. These relationships have impacted the development of care plans for individual patients as we have observed an increase in the number of pre-release meetings between patients, an HMT member and a community partner (meetings that focus on transition into the community following release). These efforts promote continuation of prisoner health care in the outside setting and reduce the stigmatization of ex-prisoner patients when they are treated in the local medical community (these patients become known entities in the community health system, instead of strangers).
Outcomes of the HMT implementation in Geneva Outcomes according to the European CPT rules The goal of the Geneva prison health re-design was to guarantee prisoners access to a type of medical care that was independent of the judicial system and equivalent to the care provided to the general population. Our aim was to include prevention and promotion of health according to the European CPTrules with improved consistency and quality. In the three years since the HMT came into being, the following goals have been achieved: 1. Access to a doctor is now guaranteed in every prison, regardless of the crime and socioeconomic status of the person. 2. Equivalence of care is fully observed (for example, whereas no patient had received antiviral hepatitis treatment before, four individual patients have now received antiviral therapy for hepatitis C since the HMT’s inception). 3. Patients consent and confidentiality is adhered to. 4. Preventive health care is offered on a wide spectrum with novel universal prevention programs: B
NSP are available in every facility.
B
Group educational sessions on various health promotion themes are offered on a regular basis in each facility (34 sessions done since 2010). Viral hepatitis, AIDS and other sexually transmitted diseases, overdose prevention and social skills training continue to be a major topic that we address in our sessions. Topics like low back pain, sports safety and nutrition are in preparation for group sessions (we already offer individual counseling sessions on these topics at the patient’s request).
B
Stress reduction techniques for patients on an individual and group level (started in 2011 and increased since then: 29 group sessions in 2011, 58 group sessions in the first nine months of 2012). In these sessions, nurses teach patients how to address symptoms of anxiety and relaxation techniques – with the ultimate purpose of reducing patients’ reliance on medication. Patients have expressed great satisfaction to nurses about these sessions, while prison staff is also supportive of the classes.
5. Humanitarian assistance: the HMT advocates for populations with a history of vulnerability. 6. Professional independence. 7. Professional competence: health care is provided for by prison medicine experts, employed by the community’s central HUG health system.
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From the perspective of the patients and partners Formal methods of evaluation for the HMT are in development, but we have also gauged our progress and adjusted our implementation based on the following indicators/evidence: B
patient feedback during HMT consults;
B
discussions with part-time doctors based at each prison;
B
meetings with penitentiary office leadership at least every two months and almost daily exchanges with prison staff;
B
provider reports within the HMT; and
B
increased communication and transition building with community health sites, who focus on issues like addiction (drug, alcohol, tobacco) and primary care services for the vulnerable.
We have heard from patients that they value the continuity of their treatments because the same medical file follows the patient upon transfer to another level of medical care or another detention facility in Geneva; there is rarely the burden of ‘‘re-telling’’ their story to a new medical team or the re-negotiation of diagnostics tests and medicines. They express trust in the HMT’s care – citing the team’s independence of the judicial system and communication with other health services, as important factors. Doctors who have part-time contracts at each facility (and who usually follow in patient care with the HMT) have expressed their gratitude about the support they have received from our team in being able to follow the European prison rules, and shared reflections in challenging cases (ethics consultations). They especially appreciate the nurses’ gate-keeping work and the HMT’s role in promoting the circulation of medical information from or to health partners within and outside the prison system. They state that this saves doctor time and improves the prisoners’ quality of care. Penitentiary office leadership and prison partners particularly recognize what they have nicknamed the ‘‘health hotline’’ – the ability to call the HMT at any time during the working day (as explained before). Because they have a quick method of consultation, they have noticed a reduction in outside transfers of prisoners for health problems, which is an important issue to these stakeholders in terms of security (less transfers in and out of the prison) and cost. As the HMT team, we recognize an improved visibility of prison medicine that this new model has brought about – a visibility that has accelerated the integration of prison medicine into community health services. We now see bi-directional contact initiatives with community and prison partners. These individuals are now contacting us when they have knowledge that one of their patients will be entering the prison system, thus taking the initiative themselves to ensure appropriate continuity of care for imprisoned patients.
Limitations, next steps Of course, the HMT model is not well suited for every setting, potentially for large prison centers that are far apart. Other setting types may require a continual full time team to be based at the prison. From our experience, some of the factors that may be considered when deciding on whether an HMT is the ‘‘right fit’’ for a prison network are: 1. size; 2. detention regime; 3. level of security of the prison (in high or maximum security settings, the admissions intake procedure may be more time-consuming and complicated); 4. demographic factors (female-only, adolescent or elderly population); 5. proximity between prisons; and 6. whether a central base is possible.
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In our case, the main driver was the fact that detention facilities in Geneva are too small to justify full-time local health teams at each site. Thus, a mobile team was a fitting solution. The HMT experience has facilitated the delivery of predictable, evidence-based, high-quality care in accordance with European CPT rules. In addition, having a centralized team made up of the same people encourages coordination and continuity of healthcare (on arrival from and release into the community) in a more streamlined and efficient process. In terms of next steps, we continue in strengthening our community network and increasing the number of partners. This strategy improves continuity of patient care, both during imprisonment and after release and it curbs the stigma felt by our patients when they return to care in these local communities. Continuous training and education in prison health for prison staff is also an important next-step and we are looking at ways to increase these opportunities (not only to improve and diversify services for our patients, but also to increase the skills and knowledge of all staff regarding the specialty of urban health). An important problem that we still face is finding better paradigms for treatment management. We described above what we do now in regards to medication management, but better alternatives must be pursued so that prisoners, who have been evaluated and found to be reliable, can have some autonomy regarding their medication. One important issue that remains to be solved is the availability of OST for drug-addicted patients. It is frustrating that substitution therapy is still not an option in every facility. This type of therapy should be possible everywhere and the HMT will continue to work with individual heads-of-facilities and the penitentiary office to achieve this goal.
Conclusions In an ideal world, prison health is delivered under the constructs that build the fundamental principles of prison medicine (CPT, 2006): access to a health care professional, equivalence of care, patient consent, confidentiality, humanitarian interventions, professional competence and independence. The ideal prison model achieves the following key processes and outcomes: 1. uniformity of practices and care through central leadership; 2. detailed policy and procedures; 3. qualified training and supervision; 4. performance measurement by sites and in the aggregate with the potential for adaptation based on real-time data; and 5. integration into community health care services. The HMT reaches towards achieving these processes and outcomes, with as much observance of these fundamental principles as possible. We do this by employing a framework that is particularly well suited for small and geographically close prison facilities. But this has not been easy. Given the inevitable real-world barriers (prison structures, bureaucracy and fear of change), compromises have had to be made and certain programs have been put on hold. But this has not deterred our vision for change. We would encourage other prison health providers to do the same – developing a program of core content and centralized health delivery that is in accordance with prison health principles and reputable leader-organization guidelines; but of course with an adaptable periphery that is suited to the needs, challenges, institutional barriers and stakeholder perspectives of the prison system that one wishes to reform. We particularly stress the importance of partnering in this process from start to finish, an indispensable component to our approach.
References Council of Europe (2006), ‘‘Recommendation of the committee of ministers to member states on the European prison rules’’, paper presented at the 952nd Meeting of the Ministers’ Deputies, 11 January.
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CPT (2006), The CPT Standards, CPT-Rev. 2006, European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment, available at: www.cpt.coe.int/en/documents/engstandards-prn.pdf (accessed 28 November 2012). European Court of Human Rights (2005), ‘‘Case Nevmerjitski Against Ukraine’’, Requ. No 54825/00, European Court of Human Rights, Strasbourg, 12 October. Fazel, S. and Baillargeon, J. (2011), ‘‘The health of prisoners’’, The Lancet, Vol. 377 No. 9769, pp. 956-65. Ferszt, G.G. (2011), ‘‘Who will speak for me? Advocating for pregnant women in prison’’, Policy, Politics and Nurse Practice, Vol. 12 No. 4, pp. 254-6. Fraser, A., Gatherer, A. and Møller, L. (2007), ‘‘Social justice, public health and the vulnerable: health in prisons raises key public health issues’’, Public Health, Vol. 123 No. 6, pp. 407-9. Geneva Declaration 2012 on Health Care in Prison (2012), Proceedings of the 6th European Conference on Health Promotion in Prison, Geneva, Switzerland, 1-3 February, available at: http://ump.hug-ge.ch/ (accessed 28 November 2012). Golzari, M., Hunt, S.J. and Anoshiravani, A. (2006), ‘‘The health status of youth in juvenile detention facilities’’, Journal of Adolescent Health, Vol. 38 No. 6, pp. 776-82. Iacopino, V. and Xenakis, S.N. (2011), ‘‘Neglect of medical evidence of torture in Guanta´namo Bay: a case series’’, PLoS Medicine, Vol. 8 No. 4, p. e1001027. International Harm Reduction Association (2012), The Global State of Harm Reduction 2012: Towards an Integrated Response, Harm Reduction International, London, available at: www.ihra.net/files/2012/07/ 24/GlobalState2012_Web.pdf (accessed 28 November 2012). Møller, L., Stover, H., Jurgens, R., Gatherer, A. and Nikogosian, H. (2007), Health in Prisons: A WHO Guide to the Essentials in Prison Health, World Health Organization Regional Office for Europe, Copenhagen, available at: www.euro.who.int/__data/assets/pdf_file/0009/99018/E90174.pdf (accessed 28 November 2012). Pirruccio, S. (2011), ‘‘Oral communication of the director of the prison ‘Casa di Reclusione’’’, Padova, Italy, paper presented at Throughcare 2011 Congress ‘‘Health in Prison and Throughcare: Provision and Continuity of Care for Those in the Criminal Justice System’’, Abano Terme, Italy, 5-7 October. Pont, J., Sto¨ver, H. and Wolff, H. (2012), ‘‘Dual loyalty in prison health care’’, American Journal of Public Health, Vol. 102 No. 3, pp. 475-80. Republic and Canton of Geneva (2000), Health and Care in Prison Setting, Decree of the Council of State, 27 September. Republic and Canton of Geneva (2011), Cantonal Statistics, available at: www.ge.ch/statistique/tel/ domaines/01/01_02_1/T_01_02_1_1_2012.xls (accessed 28 November 2012). Rieder, J.P., Gravier, B., Bertrand, D., Pasche, C., Bodenmann, P. and Wolff, H. (2010), ‘‘Health in prison: shared vulnerability between detainees and health professionals’’, Revue Me´dicale Suisse, Vol. 6 No. 257, pp. 1462-5. Stojkovic, S. (2007), ‘‘Elderly prisoners: a growing and forgotten group within correctional systems vulnerable to elder abuse’’, Journal of Elder Abuse and Neglect, Vol. 19 Nos 3/4, pp. 97-117. Swiss Academy of Medical Sciences (2002), ‘‘Medical practice on detained people’’, The Senate, 28 November. Swiss Confederation (1981), Civil Code, Art. 397a-397f, Entered into force on 1 January. Swiss Federal Statistical Office (2008), Swiss Health Survey 2007, First Findings, OFS, Neuchaˆtel. Tan, J.A., Joseph, T.A. and Saab, S. (2008), ‘‘Treating hepatitis C in the prison population is cost-saving’’, Hepatology, Vol. 48 No. 5, pp. 1387-95. Wolff, H., Sebo, P., Haller, D.M., Eytan, A., Niveau, G., Bertrand, D., Ge´taz, L. and Cerutti, B. (2011), ‘‘Health problems among detainees in Switzerland: a study using the ICPC-2 classification’’, BMC Public Health, Vol. 11, p. 245.
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World Health Organization (2010), Analysis of the Prison Health System in the Kyrgyz Republic, World Health Organization Regional Office for Europe, Copenhagen, available at: www.euro.who.int/__data/ assets/pdf_file/0005/126473/e94437.pdf (accessed 28 November 2012). World Medical Association (1991), ‘‘WMA Declaration of Malta on hunger strikers’’, Adopted by the 43rd World Medical Assembly, St Julians, Malta, November 1991, and Editorially Revised by the 44th World Medical Assembly, Marbella, Spain, September 1992, and Revised by the 57th WMA General Assembly, Pilanesberg, October 2006, available at: www.wma.net/en/30publications/10policies/h31/ (accessed 28 November 2012).
Further reading Swiss Confederation (2008), Federal Law on Narcotics and Psychoactive Products, 1951, Modified on 30 November.
Corresponding author Hans Wolff can be contacted at: [email protected]
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Jean-Pierre Rieder, Alejandra Casillas, Ge´rard Mary, Anne-Dominique Secretan, Jean-Michel Gaspoz and Hans Wolff are based in the Unit of Penitentiary Medicine, Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland.
Abstract Purpose – In the past, health management in Geneva’s six post-trial prisons had been variable and inconsistent. In 2008, the unit of penitentiary medicine of the Geneva University Hospitals was mandated to re-organize and provide health care at all six prison facilities. The specific aim of this paper is to outline the example as a practical solution to some of the common challenges in unifying the structure and process of health services across multiple small facilities, while meeting European prison health and local quality standards. Design/methodology/approach – Geneva’s post-trial prisons are small and close to one another in geographical proximity – ideal conditions for the construction of a health mobile team (HMT). This multidisciplinary mobile team operated like a community ambulatory care model; it was progressively launched in all prison facilities in Geneva. The authors incorporated an implementation strategy where health providers partnered with prison and community stakeholders in the health delivery model’s development and adaption process. Findings – The model’s strategic initiatives are described along the following areas, in light of other international prison health activity and prior care models: access to a health care professional, equivalence of care, patient consent, confidentiality, humanitarian interventions, and professional competence and independence. Originality/value – From the perspective of the HMT members, the authors provide the ‘‘lessons learned’’ through this experience, especially to providers who are working on prison health services reform and coordination improvement. The paper particularly stresses the importance of partnering with community health stakeholders and prison staff, a key component to the approach. Keywords Prisons, Mobile health unit, Health care team, Community health network, Interdisciplinary health team, Health care quality, Access, Evaluation, Switzerland, Health services Paper type Case study
List of acronyms CPT GP HMT HUG OST WHO
¼ European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment ¼ general practitioner ¼ health mobile team ¼ Geneva University Hospitals ¼ opioid substitution therapy ¼ World Health Organization
Background: benchmarks and organization of prison health in Geneva Geneva, one of 26 Swiss cantons, measures 245.6 km2 for 467,748 residents (Republic and Canton of Geneva, 2011). Geneva possesses the largest pre-trial prison in Switzerland (Champ-Dollon, 370 places), as well as six post-trial prisons with space for a total of 165 people: one for women (nine places) and five for men (18-68 places). The post-trial prisons employ two detention regimens: ordinary (full-time detention) or external work/semi-detention (detainees go to work during the day but stay at the facility at night and on weekends) (Table I).
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DOI 10.1108/17449201311310779
Table I Post-trial detention facilities in Geneva and their main characteristics Facility
Inmate capacity
La Brenaz
68 (men)
Favra
25 (men)
Montfleury
18 (men)
Raint Parc
9 (women)
La Vallon
24 (men)
Villars
21 (men)
Characteristics Standard detention Mostly undocumented immigrants Standard detention Mostly undocumented immigrants External work Socio-educational environment Mostly Swiss or documented immigrants Standard detention, semi-detention, and external work Swiss, documented and undocumented migrants External work Socio-educational environment Mostly Swiss or documented immigrants Standard detention, semi-detention, and external work Mostly Swiss or documented immigrants
Notes: Standard detention – full-time detention; semi-detention – part-time detention for people with a job; external work – part-time detention for people with a job after a period of ordinary detention and prior to release
The penitentiary medicine unit is now managed by the Geneva University Hospitals (HUG) system. Independent of prison administration and organized according to cantonal law (Republic and Canton of Geneva, 2000), the unit provides care in compliance with recommended standards (Swiss Academy of Medical Sciences, 2002; Council of Europe, 2006; Møller et al., 2007) (Table II). However, up until 2008, health care in the post-trial facilities had been organized in a variable and inconsistent manner: some prisons employed a nurse and/or a physician, while others had only the community emergency system as a resource. After an internal review between the local government, HUG and the Geneva penitentiary office, the involved stakeholders deemed that the prison health system was currently insufficient and needed re-organization.
Prison health mobile team: aims and conception In 2008, HUG was tasked by the cantonal government to organize and coordinate health care among all of the cantonal facilities to ensure independent, un-biased, provider-driven, quality care, in collaboration with community and prison staff partner feedback. The purpose of coordination was to standardize health care activities in the various prison facilities, in order to achieve more consistent adherence to prison health guidelines and unit congruence regarding health-services offered. Table II Fundamental principles of prison medicine Access to a doctor
Any detained person must have access to a doctor at any moment, whatever his/her judiciary or administrative status may be Equivalence of care For a given health issue, detained people must receive care that is equivalent to the health care given to un-imprisoned people of the same region Patient consent Prisoners with decision-making capacity have the right to informed consent for all treatments and procedures, and their decisions must be respected, as done for patients residing in the community Confidentiality Health providers must safeguard the confidentiality of medical information about detained patients Sanitary prevention In addition to individual care, prison health services have a social and preventive medicine mission, particularly with regard to hygiene, transmittable diseases, suicide, violence, and the preservation of social and family ties Humanitarian Health staff in prison should give special attention to groups who are particularly vulnerable: (pregnant) intervention women, immigrants, youth, the elderly, the mentally ill, and the critically/terminally ill Professional competence Health staff in prison should have specific skills and knowledge regarding health topics of high relevance for imprisoned people Professional Health staff in prison should be in a position to make decisions solely on the basis of medical judgment. This independence independence is better ensured when health providers are part of the community health system, separate from the control of judicial administration Source: CPT (2006)
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In re-designing care, one obvious option for improvement was to create health services for each site – with a smaller and autonomous health team at each facility. Another proposal was to have two-three teams for the group of facilities. The perceived advantage of these options was the continued visibility of health providers. But from anecdotal experiences, we quickly agreed that such plans would not be realistic or sustainable given their high financial costs, potential lack of coordination, inefficiency and ineffective use of resources. Geneva’s post-trial facilities are small; they have various missions and objectives, and they each shelter specific populations (Table I). For a cluster of small facilities, we envisioned that a part-time, mobile, and easily accessible health team could respond to prisoner health problems without requiring the continued and costly presence of a doctor or a nurse. Because of their small sizes and the short travelling distances in Geneva, the model of a singular primary mobile team was quickly accepted as the best option: it required less staff and equipment, but would have a central structure to facilitate flow of information between team members and coordination among the facilities. Our health mobile team (HMT) is multidisciplinary. It is comprised of nurses, a general practitioner (GP), a psychiatrist, a psychologist, and a secretary. Our team offers access to dental health providers, working in close collaboration with the dentists of Champ-Dollon (the HMT’s ‘‘home base’’). The team collaborates with the prisons’social workers, all-the-while maintaining professional confidentiality. The care management concept is based on the European Prison Rules (Council of Europe, 2006) and the European Committee for the Prevention of Torture (CPT) rules (CPT, 2006). We will discuss the HMT’s main initiatives along the following action areas (in italics below): access to a health care professional, equivalence of care, patient consent, confidentiality, humanitarian interventions, professional competence and independence. We also make referential comparisons to what other international prison models have done in the past in the context of these action areas. Access to a health care professional Access to a health care professional is organized in different ways among prisons worldwide. The access process varies from nurses or a doctor available 24 h a day within the prison, e.g. Champ-Dollon in Geneva/Switzerland (Wolff et al., 2011), Casa di Reclusione in Padova, Italy (Pirruccio, 2011), to no health professional available (complete dependence on the local community’s emergency room services). Similar mechanisms existed in Geneva before the launch of the HMT. Some facilities were equipped with a daily nurse with the help of a visiting doctor twice a week. Other units simply had the one nurse on-call, without any sort of physician backup ensured. Neither example was efficient nor in accordance with the European rules in terms of ensuring access. Our current model is an ambulatory team with nurse gate-keeping. The team works on weekdays (Monday-Friday, from 7 am to 6 pm) and has its primary base in the largest facility (La Brenaz, 68 places). The team visits the other facilities on a regular basis (pre-appointed days) with a frequency proportionate to each one’s size and according to acute need. An interpreting service is used when needed. All new inmates undergo a health screening with a nurse within 24-48 h of admission. The purpose of this screen is to identify any problems needing more immediate attention: addictions, infectious disease risk, suicidal ideation and need for continuing/initiating treatment. The nurse refers the patient to the most appropriate health professional on the team, as he/she sees fit. If necessary, the GP then refers the person to consult with a specialist, as done with any community-dwelling patient at the HUG. Two prisoner-only wards at the HUG (medical and psychiatric) care for prisoners in the inpatient setting. In the case of an urgent and acute medical problem, the prison officers call an HMT nurse for evaluation. Outside of working hours, the community emergency network is the appropriate health resource. If the problem appears to be an emergency, prison officers have the discretion to call an ambulance at any moment. In the time since the HMT has been implemented, there has been much discussion between prison staff and HMT providers
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about when to escalate care. In response to these discussions, our nurses, GP, and local pharmacists have developed a guideline outlining appropriate staff responses for ’’everyday problems’’ (e.g. pain, anxiety, small wounds), indicating an appropriate course of action: from basic symptomatic treatment on issues that can wait on provider evaluation, to more escalated measures like immediate evaluation by the HMT, or calling emergency medical services. However, during working hours, the prison officers are encouraged to call the HMT for any prisoner medical issue if the next course of action is not obvious. Equivalence of care Matching health care to what is offered in the surrounding community is a challenge. Our goal is ambitious given that the team seeks to provide equivalent care with respect to all aspects of health promotion, prevention, diagnostic processes and therapies for every detainee regardless of his/her social or administrative status. Worldwide, the failure to achieve equivalence of care in prison is a major issue (CPT, 2006). This is simply because the volume of challenging medical issues among this population is high (Fazel and Baillargeon, 2011). For example, drug addictions are far more prevalent among detainees compared to the general population (Table III). Therefore, successful therapeutic plans like opioid substitution therapy (OST) and needle-syringe exchange programs (NSP) are alternatives that should be offered to candidate patients who meet medical treatment criteria. However, OST is available in 77 countries only and among this small group, only 41 of these countries offer OST in prison (International Harm Reduction Association, 2012). In addition, the situation is far worse than the statistics first indicate – the presence of prison OST in one country does not translate to OST availability in every prison of that country. The situation for NSP is similar (International Harm Reduction Association, 2012). Following the community’s local law and in the name of equivalence of care, our team provides comparable health services in prison to those available in the community, including OST and NSP. The team also provides infectious disease screenings, vaccinations and treatment, thus focusing our efforts on aspects of primary, secondary and tertiary prevention. Patient consent and patient decision-making Informed consent for patients is required for every medical intervention that the team delivers. The HMT never engages in medical treatment against the patient’s will, except in cases of psychiatric commitment and where patients are deemed incompetent, per the same legal criteria employed in the community (Swiss Confederation, 1981). Unfortunately however, violations of patient consent and decision-making are not uncommon in prison settings. Common examples are international cases of prisoner hunger strikers followed by forcedfeedings of these individuals; a violation of the European Court of Human Rights (2005) (Lacopino and Xenakis, 2011). In our setting, in contrast to several countries, competent hunger strikers are never force-fed and their advance directives about feeding procedures (and all treatments) are honored should they lose consciousness. This is all in accordance with the European rules and the Malta Declaration (World Medical Association, 1991).
Table III Types of addiction among the Swiss general population (2007) (Swiss Federal Statistical Office, 2008) and the detainees of Champ-Dollon remand prison, Switzerland (2007-2008) (Wolff et al., 2011)
Substance Alcohol Tobacco Benzodiazepines Heroin Cocaine Cannabis
Prevalence (general Swiss population) (%)
Prevalence (detainees of Champ-Dollon) (%)
4.7 30.5 1.3-2.1 ,1 ,1 9-31 (depending on age)
20 61 22 12 20 28
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Confidentiality Because the HMT promotes patient autonomy and right to confidentiality, any inmate seeking a health visit can place a sealed written request in our letterbox (located at each facility). Although this appears simple, it is very efficient. Requests are sometimes rudimentary but these are systematically evaluated by a nurse to determine the urgency level and to whom the inmate should be referred. Nurses are able to resolve numerous problems without involving the doctor. Urgent requests are immediately relayed through prison staff. However, consultations never take place in the presence of prison staff. Medical information is not given to anyone without authorization by the patient (even to his/her lawyer or a judge). Humanitarian interventions All detainees are part of a vulnerable population. However, within this population, certain subgroups like women, minors, immigrants, those with poor language proficiency (non-native speakers), the mentally ill, and elderly detainees are particularly vulnerable (Ferszt, 2011; Rieder et al., 2010; Fraser et al., 2007; Stojkovic, 2007; Golzari et al., 2006; Wolff et al., 2011). In our operations, these groups receive special attention in order to ensure that they are not subject to abuse or mistreatment given their vulnerable status, that they are well-informed about their rights and that they have access to an interpreter if needed. For example, in cases of patients reporting violence or any abuse to their providers, a medical incident report is written by the team in order to allow the incarcerated patient to make a formal complaint. If any authorities (police, prison officers) are involved, an independent ombudsman acting as a correctional and police investigator is systematically informed. Another example of these humanitarian efforts in prison is the specific services that are made available to our patients who would otherwise have no recourse to such specialized treatments, even in the community setting. The HMToffers services such as mental health and addiction therapies and also costly treatments for infectious diseases like hepatitis C. This is simultaneously an altruistic action, as treating these diseases improve the local communities. Tan et al. (2008) reported that treating hepatitis C in prison is not only cost effective, but also confers health benefits in terms of the individual and the public health status. Therefore, imprisonment can be considered an important opportunity for prison staff, health providers and public health administrators to impact the well-being of their community: treating the illnesses of the most difficult-to-reach populations who live at the margins of society, whose illnesses and outcomes also have a significant effect on the health of the community. Professional competence Providers with up-to-date knowledge and skills are crucial in ensuring high-quality standards. The Kyrgyz example illustrates the limitations met by under-trained or non-specifically educated teams. In this setting, medical providers were mostly early in their career course or training, without sufficient practical and/or professional prison medicine experience, per the World Health Organization (WHO) evaluation. Problems in this setting were inadequate disease monitoring, un-organized medical consultations and failure of medical follow-up, which (per the report) were partly due to the lack of experience and knowledge of prison health among medical providers (WHO, 2010). In contrast, all members of the HMT are employed by the HUG and must satisfy the same quality standards and continuing medical education as those seasoned expert colleagues working in other units of the university hospitals. They have all had extensive training and experience in prison health care (recruited from Champ-Dollon) and are effectively ‘‘specialists’’ in prison medicine. Professional independence The European prison rules and the European CPT recommend that prison health providers must be linked to the civil health authority (department of health, local health ministry) and function independently of the correctional setting from an employment standpoint. The HMT model functions in this manner. This ensures supervisorial distance from the prison and facilitates medical decisions with the patient’s best interests in mind (Geneva Declaration on Health Care in Prison, 2012). The professional independence of the HMT is safeguarded by
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the fact that all medical responsibility and liability fall under the auspices of the HUG. This prevents dual loyalty conflicts or other ethical problems that can occur in settings where health professionals are employed by the justice department/prison (Pont et al., 2012). However, ‘‘independence’’ does not translate into ‘‘avoidance.’’ Regular planned meetings with prison directors are indispensable in our model, where we jointly monitor and discuss any complicated cases that need special attention. These meetings have also been a way to convey positive feedback to our partners (giving commendation to prison activities, communication and staff actions which facilitate quality health delivery by the HMT). These consistent meetings have improved coordination and collaboration over time, as our respective roles have become more clearly defined to all involved: the prison administration being responsible for the prison’s security operations, while the HMT directs health services for patients and acts as the safeguard for fundamental health principles in prison (Table II).
Launch of the HMT: working together From the outset, one of our greatest challenges was to implement reform without provoking a surge of resistance from prison custodial staff. Several meetings with the prison partners before and after our launch identified multiple issues specific to each facility and the need for the mobile team to build collegial relationships with prison leaders and everyday staff. We provide specific examples of our collaborative approach drawing from the following two experiences: 1. compromising with prison leadership in relation to medication management; and 2. outreach to community organizations, vital to achieving patient continuity of care. Partnering and relationship building with prison staff and community colleagues, where all stakeholders had a valued and respected voice, was a key ingredient for the model’s implementation. This helped our partners view the new presence of the HMT providers as an advantage, rather than a threat. Working together – prison leadership and medication management Medication management in prison is a complicated challenge as it reveals the perhaps competing, and often not always aligned, goals of health professionals and custodial staff. In accordance with the health principles of equivalence of care, confidentiality, and autonomy, detainees should have the right to manage their own treatment. However, most of our prison management partners did not accept this framework. Initially, heads-of-facilities preferred total security and control of medication management – even in cases where a prisoner’s stay was short or his/her release was soon approaching. But after many meetings, compromises were possible given our stable presence in the prisons and continued conversations with prison leaders and partners. These conversations sensitized the prison management to the HMT’s ultimate mission: to prepare inmates for release into the community in the best condition possible (mentally and physically), so as to become contributing members of society. Ironically, settings in which the prison’s management refused to impose drug management duties on prison wardens, worked in our favor. This paradigm completely removed prison officers from the equation and more easily promoted autonomy, self-responsibility and the right to confidentiality. However, these types of leadership reactions also made it difficult for our team to administer therapies like OST, since these require direct observation: without prison leadership buy-in and assistance, our man-power resources would not have been capable of providing such oversight. Thus, medication management was tailored to each facility, but never betrayed the core principles of prison health. Currently in some facilities, the nurses administer individual treatments twice a week to each patient. In other prisons, the nurses prepare the weekly pillboxes, leaving the wardens to present the boxes to the patient several times a day (and the patient takes his/her medications at that moment). In all cases, the wardens are solely responsible for identifying the patients and never for the content of the pillboxes.
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Working together – community outreach and continuity of patient care In conjunction with local community health services, the HMT communicates with all previous, present and future partners pertinent to the patient’s case (e.g. prison or community health services, addiction medicine, psychiatry or other specialty services, migrant care centers, non-government and charity organizations). Because the HMT is a recent development, the team has been extremely proactive in making contacts and establishing regular, long-term communication with community organizations that are pertinent to the prisoner population. These relationships have impacted the development of care plans for individual patients as we have observed an increase in the number of pre-release meetings between patients, an HMT member and a community partner (meetings that focus on transition into the community following release). These efforts promote continuation of prisoner health care in the outside setting and reduce the stigmatization of ex-prisoner patients when they are treated in the local medical community (these patients become known entities in the community health system, instead of strangers).
Outcomes of the HMT implementation in Geneva Outcomes according to the European CPT rules The goal of the Geneva prison health re-design was to guarantee prisoners access to a type of medical care that was independent of the judicial system and equivalent to the care provided to the general population. Our aim was to include prevention and promotion of health according to the European CPTrules with improved consistency and quality. In the three years since the HMT came into being, the following goals have been achieved: 1. Access to a doctor is now guaranteed in every prison, regardless of the crime and socioeconomic status of the person. 2. Equivalence of care is fully observed (for example, whereas no patient had received antiviral hepatitis treatment before, four individual patients have now received antiviral therapy for hepatitis C since the HMT’s inception). 3. Patients consent and confidentiality is adhered to. 4. Preventive health care is offered on a wide spectrum with novel universal prevention programs: B
NSP are available in every facility.
B
Group educational sessions on various health promotion themes are offered on a regular basis in each facility (34 sessions done since 2010). Viral hepatitis, AIDS and other sexually transmitted diseases, overdose prevention and social skills training continue to be a major topic that we address in our sessions. Topics like low back pain, sports safety and nutrition are in preparation for group sessions (we already offer individual counseling sessions on these topics at the patient’s request).
B
Stress reduction techniques for patients on an individual and group level (started in 2011 and increased since then: 29 group sessions in 2011, 58 group sessions in the first nine months of 2012). In these sessions, nurses teach patients how to address symptoms of anxiety and relaxation techniques – with the ultimate purpose of reducing patients’ reliance on medication. Patients have expressed great satisfaction to nurses about these sessions, while prison staff is also supportive of the classes.
5. Humanitarian assistance: the HMT advocates for populations with a history of vulnerability. 6. Professional independence. 7. Professional competence: health care is provided for by prison medicine experts, employed by the community’s central HUG health system.
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From the perspective of the patients and partners Formal methods of evaluation for the HMT are in development, but we have also gauged our progress and adjusted our implementation based on the following indicators/evidence: B
patient feedback during HMT consults;
B
discussions with part-time doctors based at each prison;
B
meetings with penitentiary office leadership at least every two months and almost daily exchanges with prison staff;
B
provider reports within the HMT; and
B
increased communication and transition building with community health sites, who focus on issues like addiction (drug, alcohol, tobacco) and primary care services for the vulnerable.
We have heard from patients that they value the continuity of their treatments because the same medical file follows the patient upon transfer to another level of medical care or another detention facility in Geneva; there is rarely the burden of ‘‘re-telling’’ their story to a new medical team or the re-negotiation of diagnostics tests and medicines. They express trust in the HMT’s care – citing the team’s independence of the judicial system and communication with other health services, as important factors. Doctors who have part-time contracts at each facility (and who usually follow in patient care with the HMT) have expressed their gratitude about the support they have received from our team in being able to follow the European prison rules, and shared reflections in challenging cases (ethics consultations). They especially appreciate the nurses’ gate-keeping work and the HMT’s role in promoting the circulation of medical information from or to health partners within and outside the prison system. They state that this saves doctor time and improves the prisoners’ quality of care. Penitentiary office leadership and prison partners particularly recognize what they have nicknamed the ‘‘health hotline’’ – the ability to call the HMT at any time during the working day (as explained before). Because they have a quick method of consultation, they have noticed a reduction in outside transfers of prisoners for health problems, which is an important issue to these stakeholders in terms of security (less transfers in and out of the prison) and cost. As the HMT team, we recognize an improved visibility of prison medicine that this new model has brought about – a visibility that has accelerated the integration of prison medicine into community health services. We now see bi-directional contact initiatives with community and prison partners. These individuals are now contacting us when they have knowledge that one of their patients will be entering the prison system, thus taking the initiative themselves to ensure appropriate continuity of care for imprisoned patients.
Limitations, next steps Of course, the HMT model is not well suited for every setting, potentially for large prison centers that are far apart. Other setting types may require a continual full time team to be based at the prison. From our experience, some of the factors that may be considered when deciding on whether an HMT is the ‘‘right fit’’ for a prison network are: 1. size; 2. detention regime; 3. level of security of the prison (in high or maximum security settings, the admissions intake procedure may be more time-consuming and complicated); 4. demographic factors (female-only, adolescent or elderly population); 5. proximity between prisons; and 6. whether a central base is possible.
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In our case, the main driver was the fact that detention facilities in Geneva are too small to justify full-time local health teams at each site. Thus, a mobile team was a fitting solution. The HMT experience has facilitated the delivery of predictable, evidence-based, high-quality care in accordance with European CPT rules. In addition, having a centralized team made up of the same people encourages coordination and continuity of healthcare (on arrival from and release into the community) in a more streamlined and efficient process. In terms of next steps, we continue in strengthening our community network and increasing the number of partners. This strategy improves continuity of patient care, both during imprisonment and after release and it curbs the stigma felt by our patients when they return to care in these local communities. Continuous training and education in prison health for prison staff is also an important next-step and we are looking at ways to increase these opportunities (not only to improve and diversify services for our patients, but also to increase the skills and knowledge of all staff regarding the specialty of urban health). An important problem that we still face is finding better paradigms for treatment management. We described above what we do now in regards to medication management, but better alternatives must be pursued so that prisoners, who have been evaluated and found to be reliable, can have some autonomy regarding their medication. One important issue that remains to be solved is the availability of OST for drug-addicted patients. It is frustrating that substitution therapy is still not an option in every facility. This type of therapy should be possible everywhere and the HMT will continue to work with individual heads-of-facilities and the penitentiary office to achieve this goal.
Conclusions In an ideal world, prison health is delivered under the constructs that build the fundamental principles of prison medicine (CPT, 2006): access to a health care professional, equivalence of care, patient consent, confidentiality, humanitarian interventions, professional competence and independence. The ideal prison model achieves the following key processes and outcomes: 1. uniformity of practices and care through central leadership; 2. detailed policy and procedures; 3. qualified training and supervision; 4. performance measurement by sites and in the aggregate with the potential for adaptation based on real-time data; and 5. integration into community health care services. The HMT reaches towards achieving these processes and outcomes, with as much observance of these fundamental principles as possible. We do this by employing a framework that is particularly well suited for small and geographically close prison facilities. But this has not been easy. Given the inevitable real-world barriers (prison structures, bureaucracy and fear of change), compromises have had to be made and certain programs have been put on hold. But this has not deterred our vision for change. We would encourage other prison health providers to do the same – developing a program of core content and centralized health delivery that is in accordance with prison health principles and reputable leader-organization guidelines; but of course with an adaptable periphery that is suited to the needs, challenges, institutional barriers and stakeholder perspectives of the prison system that one wishes to reform. We particularly stress the importance of partnering in this process from start to finish, an indispensable component to our approach.
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World Health Organization (2010), Analysis of the Prison Health System in the Kyrgyz Republic, World Health Organization Regional Office for Europe, Copenhagen, available at: www.euro.who.int/__data/ assets/pdf_file/0005/126473/e94437.pdf (accessed 28 November 2012). World Medical Association (1991), ‘‘WMA Declaration of Malta on hunger strikers’’, Adopted by the 43rd World Medical Assembly, St Julians, Malta, November 1991, and Editorially Revised by the 44th World Medical Assembly, Marbella, Spain, September 1992, and Revised by the 57th WMA General Assembly, Pilanesberg, October 2006, available at: www.wma.net/en/30publications/10policies/h31/ (accessed 28 November 2012).
Further reading Swiss Confederation (2008), Federal Law on Narcotics and Psychoactive Products, 1951, Modified on 30 November.
Corresponding author Hans Wolff can be contacted at: [email protected]
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